Form 08-609 - Application To Practice Veterinary Medicine Page 12
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14State of Alaska
Department of Commerce, Community, and Economic Development
Division of Corporations, Business and Professional Licensing
BOARD OF VETERINARY EXAMINERS
th
333 Willoughby Avenue, 9
Floor
P.O. Box 110806
Juneau, Alaska 99811-0806
Phone: (907) 465-2550
E-mail: license@alaska.gov
Website:
VERIFICATION OF LICENSURE
Applicant: Complete this section and mail to each jurisdiction in which you hold or have held a license to practice
veterinary medicine. Some jurisdictions require a fee for completion of a license verification; you may wish to check with
that agency prior to submitting this form for completion.
Applicant Signature:
Printed Name:
License No.:
Address:
PLEASE DO NOT DETACH.
The information below must be completed by the State Licensing Board; it may not be
completed by the applicant.
PLEASE MAIL DIRECTLY TO THE STATE OF ALASKA
State of
Name of Licensee:
Type of License Granted:
License No.:
Issue Date:
Expiration Date:
Licensed by:
State Exam
National Exam
Other
Status:
Current
--
Expiration Date:
Inactive
--
Lapsed
Suspended
Revoked --
Reinstated (if applicable, please explain)
Is the above-named applicant in good standing?
Yes
No
Has the applicant’s license ever been suspended, revoked or subject to any disciplinary actions?
Yes
No
If so, for what reason?
Please provide any information you believe relevant to the applicant’s qualifications to practice as a veterinarian:
Signature
(BOARD SEAL)
Printed Name
PLEASE MAIL DIRECTLY TO:
Title
BOARD OF VETERINARY EXAMINERS
P.O. Box 110806
Juneau, AK 99811-0806
Email Address
08-609c (Rev. 09/23/16)
Verification of Licensure Page 1 of 1
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